|
KIT EXPECTANT FATHERS X-LARGE SCRUB DISPOSABLE
|
Facility
|
IP
|
$157.00
|
|
| Hospital Charge Code |
2963271
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$80.01 |
| Max. Negotiated Rate |
$150.22 |
| Rate for Payer: Aetna Commercial |
$146.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.54
|
| Rate for Payer: Cash Price |
$47.10
|
| Rate for Payer: Cigna Commercial |
$150.22
|
| Rate for Payer: Health EOS Commercial |
$145.32
|
| Rate for Payer: HFN Commercial |
$150.22
|
| Rate for Payer: Multiplan Commercial |
$130.62
|
| Rate for Payer: Preferred Network Access Commercial |
$150.22
|
| Rate for Payer: Quartz Beloit One Network |
$80.01
|
| Rate for Payer: Quartz Commercial |
$97.97
|
| Rate for Payer: WEA Trust Commercial |
$89.80
|
| Rate for Payer: WPS Commercial |
$120.94
|
|
|
KIT FAST PACK CELL SAVER ELITE 125ML CSE-FP-125V
|
Facility
|
IP
|
$2,302.00
|
|
| Hospital Charge Code |
5804219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,173.10 |
| Max. Negotiated Rate |
$2,202.55 |
| Rate for Payer: Aetna Commercial |
$2,154.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,058.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,268.86
|
| Rate for Payer: Cash Price |
$690.60
|
| Rate for Payer: Cigna Commercial |
$2,202.55
|
| Rate for Payer: Health EOS Commercial |
$2,130.73
|
| Rate for Payer: HFN Commercial |
$2,202.55
|
| Rate for Payer: Multiplan Commercial |
$1,915.26
|
| Rate for Payer: Preferred Network Access Commercial |
$2,202.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.10
|
| Rate for Payer: Quartz Commercial |
$1,436.45
|
| Rate for Payer: WEA Trust Commercial |
$1,316.74
|
| Rate for Payer: WPS Commercial |
$1,773.23
|
|
|
KIT FAST PACK CELL SAVER ELITE 125ML CSE-FP-125V
|
Facility
|
OP
|
$2,302.00
|
|
| Hospital Charge Code |
5804219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$670.34 |
| Max. Negotiated Rate |
$2,202.55 |
| Rate for Payer: Aetna Commercial |
$2,154.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,058.91
|
| Rate for Payer: Aetna Managed Medicare |
$670.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,556.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,197.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,149.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,268.86
|
| Rate for Payer: Cash Price |
$690.60
|
| Rate for Payer: Cigna Commercial |
$2,202.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,339.76
|
| Rate for Payer: Health EOS Commercial |
$2,130.73
|
| Rate for Payer: HFN Commercial |
$2,202.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,795.56
|
| Rate for Payer: Multiplan Commercial |
$1,915.26
|
| Rate for Payer: NAPHCARE Commercial |
$1,436.45
|
| Rate for Payer: Preferred Network Access Commercial |
$2,202.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.10
|
| Rate for Payer: Quartz Commercial |
$1,556.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,436.45
|
| Rate for Payer: The Alliance Commercial |
$1,197.04
|
| Rate for Payer: WEA Trust Commercial |
$1,316.74
|
| Rate for Payer: WPS Commercial |
$1,773.23
|
|
|
KIT FAST PACK CELL SAVER ELITE 225ML CSE-FP-225V
|
Facility
|
IP
|
$2,302.00
|
|
| Hospital Charge Code |
5804218
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,173.10 |
| Max. Negotiated Rate |
$2,202.55 |
| Rate for Payer: Aetna Commercial |
$2,154.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,058.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,268.86
|
| Rate for Payer: Cash Price |
$690.60
|
| Rate for Payer: Cigna Commercial |
$2,202.55
|
| Rate for Payer: Health EOS Commercial |
$2,130.73
|
| Rate for Payer: HFN Commercial |
$2,202.55
|
| Rate for Payer: Multiplan Commercial |
$1,915.26
|
| Rate for Payer: Preferred Network Access Commercial |
$2,202.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.10
|
| Rate for Payer: Quartz Commercial |
$1,436.45
|
| Rate for Payer: WEA Trust Commercial |
$1,316.74
|
| Rate for Payer: WPS Commercial |
$1,773.23
|
|
|
KIT FAST PACK CELL SAVER ELITE 225ML CSE-FP-225V
|
Facility
|
OP
|
$2,302.00
|
|
| Hospital Charge Code |
5804218
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$670.34 |
| Max. Negotiated Rate |
$2,202.55 |
| Rate for Payer: Aetna Commercial |
$2,154.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,058.91
|
| Rate for Payer: Aetna Managed Medicare |
$670.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,556.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,197.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,149.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,268.86
|
| Rate for Payer: Cash Price |
$690.60
|
| Rate for Payer: Cigna Commercial |
$2,202.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,339.76
|
| Rate for Payer: Health EOS Commercial |
$2,130.73
|
| Rate for Payer: HFN Commercial |
$2,202.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,795.56
|
| Rate for Payer: Multiplan Commercial |
$1,915.26
|
| Rate for Payer: NAPHCARE Commercial |
$1,436.45
|
| Rate for Payer: Preferred Network Access Commercial |
$2,202.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.10
|
| Rate for Payer: Quartz Commercial |
$1,556.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,436.45
|
| Rate for Payer: The Alliance Commercial |
$1,197.04
|
| Rate for Payer: WEA Trust Commercial |
$1,316.74
|
| Rate for Payer: WPS Commercial |
$1,773.23
|
|
|
KIT FATHER LARGE
|
Facility
|
IP
|
$157.00
|
|
| Hospital Charge Code |
2963284
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$80.01 |
| Max. Negotiated Rate |
$150.22 |
| Rate for Payer: Aetna Commercial |
$146.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.54
|
| Rate for Payer: Cash Price |
$47.10
|
| Rate for Payer: Cigna Commercial |
$150.22
|
| Rate for Payer: Health EOS Commercial |
$145.32
|
| Rate for Payer: HFN Commercial |
$150.22
|
| Rate for Payer: Multiplan Commercial |
$130.62
|
| Rate for Payer: Preferred Network Access Commercial |
$150.22
|
| Rate for Payer: Quartz Beloit One Network |
$80.01
|
| Rate for Payer: Quartz Commercial |
$97.97
|
| Rate for Payer: WEA Trust Commercial |
$89.80
|
| Rate for Payer: WPS Commercial |
$120.94
|
|
|
KIT FATHER LARGE
|
Facility
|
OP
|
$157.00
|
|
| Hospital Charge Code |
2963284
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.72 |
| Max. Negotiated Rate |
$150.22 |
| Rate for Payer: Aetna Commercial |
$146.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.42
|
| Rate for Payer: Aetna Managed Medicare |
$45.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$81.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$78.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.54
|
| Rate for Payer: Cash Price |
$47.10
|
| Rate for Payer: Cigna Commercial |
$150.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.37
|
| Rate for Payer: Health EOS Commercial |
$145.32
|
| Rate for Payer: HFN Commercial |
$150.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$122.46
|
| Rate for Payer: Multiplan Commercial |
$130.62
|
| Rate for Payer: NAPHCARE Commercial |
$97.97
|
| Rate for Payer: Preferred Network Access Commercial |
$150.22
|
| Rate for Payer: Quartz Beloit One Network |
$80.01
|
| Rate for Payer: Quartz Commercial |
$106.13
|
| Rate for Payer: Quartz Medicare Advantage |
$97.97
|
| Rate for Payer: The Alliance Commercial |
$81.64
|
| Rate for Payer: WEA Trust Commercial |
$89.80
|
| Rate for Payer: WPS Commercial |
$120.94
|
|
|
KIT FEMORAL ARTERY 20G 8CM SAC-00820-1A
|
Facility
|
OP
|
$772.00
|
|
| Hospital Charge Code |
5641660
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$224.81 |
| Max. Negotiated Rate |
$738.65 |
| Rate for Payer: Aetna Commercial |
$722.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$690.48
|
| Rate for Payer: Aetna Managed Medicare |
$224.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$521.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$401.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$385.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$425.53
|
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Cigna Commercial |
$738.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$449.30
|
| Rate for Payer: Health EOS Commercial |
$714.56
|
| Rate for Payer: HFN Commercial |
$738.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$602.16
|
| Rate for Payer: Multiplan Commercial |
$642.30
|
| Rate for Payer: NAPHCARE Commercial |
$481.73
|
| Rate for Payer: Preferred Network Access Commercial |
$738.65
|
| Rate for Payer: Quartz Beloit One Network |
$393.41
|
| Rate for Payer: Quartz Commercial |
$521.87
|
| Rate for Payer: Quartz Medicare Advantage |
$481.73
|
| Rate for Payer: The Alliance Commercial |
$401.44
|
| Rate for Payer: WEA Trust Commercial |
$441.58
|
| Rate for Payer: WPS Commercial |
$594.67
|
|
|
KIT FEMORAL ARTERY 20G 8CM SAC-00820-1A
|
Facility
|
IP
|
$772.00
|
|
| Hospital Charge Code |
5641660
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$393.41 |
| Max. Negotiated Rate |
$738.65 |
| Rate for Payer: Aetna Commercial |
$722.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$690.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$425.53
|
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Cigna Commercial |
$738.65
|
| Rate for Payer: Health EOS Commercial |
$714.56
|
| Rate for Payer: HFN Commercial |
$738.65
|
| Rate for Payer: Multiplan Commercial |
$642.30
|
| Rate for Payer: Preferred Network Access Commercial |
$738.65
|
| Rate for Payer: Quartz Beloit One Network |
$393.41
|
| Rate for Payer: Quartz Commercial |
$481.73
|
| Rate for Payer: WEA Trust Commercial |
$441.58
|
| Rate for Payer: WPS Commercial |
$594.67
|
|
|
KIT FLEXIMA NEPHROSTOMY CATHETER SYSTEM VTC 8F X 25CM M001271860
|
Facility
|
OP
|
$3,710.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
2973046
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,080.35 |
| Max. Negotiated Rate |
$3,549.73 |
| Rate for Payer: Aetna Commercial |
$3,472.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,318.22
|
| Rate for Payer: Aetna Managed Medicare |
$1,080.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,507.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,929.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,852.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,044.95
|
| Rate for Payer: Cash Price |
$1,113.00
|
| Rate for Payer: Cigna Commercial |
$3,549.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,159.22
|
| Rate for Payer: Health EOS Commercial |
$3,433.98
|
| Rate for Payer: HFN Commercial |
$3,549.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,893.80
|
| Rate for Payer: Multiplan Commercial |
$3,086.72
|
| Rate for Payer: NAPHCARE Commercial |
$2,315.04
|
| Rate for Payer: Preferred Network Access Commercial |
$3,549.73
|
| Rate for Payer: Quartz Beloit One Network |
$1,890.62
|
| Rate for Payer: Quartz Commercial |
$2,507.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2,315.04
|
| Rate for Payer: The Alliance Commercial |
$1,929.20
|
| Rate for Payer: WEA Trust Commercial |
$2,122.12
|
| Rate for Payer: WPS Commercial |
$2,857.81
|
|
|
KIT FLEXIMA NEPHROSTOMY CATHETER SYSTEM VTC 8F X 25CM M001271860
|
Facility
|
IP
|
$3,710.00
|
|
|
Service Code
|
HCPCS C1729
|
| Hospital Charge Code |
2973046
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,890.62 |
| Max. Negotiated Rate |
$3,549.73 |
| Rate for Payer: Aetna Commercial |
$3,472.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,318.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,044.95
|
| Rate for Payer: Cash Price |
$1,113.00
|
| Rate for Payer: Cigna Commercial |
$3,549.73
|
| Rate for Payer: Health EOS Commercial |
$3,433.98
|
| Rate for Payer: HFN Commercial |
$3,549.73
|
| Rate for Payer: Multiplan Commercial |
$3,086.72
|
| Rate for Payer: Preferred Network Access Commercial |
$3,549.73
|
| Rate for Payer: Quartz Beloit One Network |
$1,890.62
|
| Rate for Payer: Quartz Commercial |
$2,315.04
|
| Rate for Payer: WEA Trust Commercial |
$2,122.12
|
| Rate for Payer: WPS Commercial |
$2,857.81
|
|
|
KIT FLEXI-SEAL FECAL ODOR CONTROL 418000
|
Facility
|
IP
|
$3,701.00
|
|
| Hospital Charge Code |
2963010
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,886.03 |
| Max. Negotiated Rate |
$3,541.12 |
| Rate for Payer: Aetna Commercial |
$3,464.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,310.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,039.99
|
| Rate for Payer: Cash Price |
$1,110.30
|
| Rate for Payer: Cigna Commercial |
$3,541.12
|
| Rate for Payer: Health EOS Commercial |
$3,425.65
|
| Rate for Payer: HFN Commercial |
$3,541.12
|
| Rate for Payer: Multiplan Commercial |
$3,079.23
|
| Rate for Payer: Preferred Network Access Commercial |
$3,541.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,886.03
|
| Rate for Payer: Quartz Commercial |
$2,309.42
|
| Rate for Payer: WEA Trust Commercial |
$2,116.97
|
| Rate for Payer: WPS Commercial |
$2,850.88
|
|
|
KIT FLEXI-SEAL FECAL ODOR CONTROL 418000
|
Facility
|
OP
|
$3,701.00
|
|
| Hospital Charge Code |
2963010
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,077.73 |
| Max. Negotiated Rate |
$3,541.12 |
| Rate for Payer: Aetna Commercial |
$3,464.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,310.17
|
| Rate for Payer: Aetna Managed Medicare |
$1,077.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,501.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,924.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,847.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,039.99
|
| Rate for Payer: Cash Price |
$1,110.30
|
| Rate for Payer: Cigna Commercial |
$3,541.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,153.98
|
| Rate for Payer: Health EOS Commercial |
$3,425.65
|
| Rate for Payer: HFN Commercial |
$3,541.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,886.78
|
| Rate for Payer: Multiplan Commercial |
$3,079.23
|
| Rate for Payer: NAPHCARE Commercial |
$2,309.42
|
| Rate for Payer: Preferred Network Access Commercial |
$3,541.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,886.03
|
| Rate for Payer: Quartz Commercial |
$2,501.88
|
| Rate for Payer: Quartz Medicare Advantage |
$2,309.42
|
| Rate for Payer: The Alliance Commercial |
$1,924.52
|
| Rate for Payer: WEA Trust Commercial |
$2,116.97
|
| Rate for Payer: WPS Commercial |
$2,850.88
|
|
|
KIT GILL BIOPSY BRUSH G15045
|
Facility
|
IP
|
$1,269.00
|
|
| Hospital Charge Code |
2965865
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$646.68 |
| Max. Negotiated Rate |
$1,214.18 |
| Rate for Payer: Aetna Commercial |
$1,187.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,134.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$699.47
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cigna Commercial |
$1,214.18
|
| Rate for Payer: Health EOS Commercial |
$1,174.59
|
| Rate for Payer: HFN Commercial |
$1,214.18
|
| Rate for Payer: Multiplan Commercial |
$1,055.81
|
| Rate for Payer: Preferred Network Access Commercial |
$1,214.18
|
| Rate for Payer: Quartz Beloit One Network |
$646.68
|
| Rate for Payer: Quartz Commercial |
$791.86
|
| Rate for Payer: WEA Trust Commercial |
$725.87
|
| Rate for Payer: WPS Commercial |
$977.51
|
|
|
KIT GILL BIOPSY BRUSH G15045
|
Facility
|
OP
|
$1,269.00
|
|
| Hospital Charge Code |
2965865
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$369.53 |
| Max. Negotiated Rate |
$1,214.18 |
| Rate for Payer: Aetna Commercial |
$1,187.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,134.99
|
| Rate for Payer: Aetna Managed Medicare |
$369.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$857.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$659.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$633.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$699.47
|
| Rate for Payer: Cash Price |
$380.70
|
| Rate for Payer: Cigna Commercial |
$1,214.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$738.56
|
| Rate for Payer: Health EOS Commercial |
$1,174.59
|
| Rate for Payer: HFN Commercial |
$1,214.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$989.82
|
| Rate for Payer: Multiplan Commercial |
$1,055.81
|
| Rate for Payer: NAPHCARE Commercial |
$791.86
|
| Rate for Payer: Preferred Network Access Commercial |
$1,214.18
|
| Rate for Payer: Quartz Beloit One Network |
$646.68
|
| Rate for Payer: Quartz Commercial |
$857.84
|
| Rate for Payer: Quartz Medicare Advantage |
$791.86
|
| Rate for Payer: The Alliance Commercial |
$659.88
|
| Rate for Payer: WEA Trust Commercial |
$725.87
|
| Rate for Payer: WPS Commercial |
$977.51
|
|
|
KIT GOOSE NECK SNARE 25mm
|
Facility
|
OP
|
$3,539.00
|
|
| Hospital Charge Code |
2973398
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,030.56 |
| Max. Negotiated Rate |
$3,386.12 |
| Rate for Payer: Aetna Commercial |
$3,312.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,165.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,030.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,392.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,840.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,766.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,950.70
|
| Rate for Payer: Cash Price |
$1,061.70
|
| Rate for Payer: Cigna Commercial |
$3,386.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,059.70
|
| Rate for Payer: Health EOS Commercial |
$3,275.70
|
| Rate for Payer: HFN Commercial |
$3,386.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,760.42
|
| Rate for Payer: Multiplan Commercial |
$2,944.45
|
| Rate for Payer: NAPHCARE Commercial |
$2,208.34
|
| Rate for Payer: Preferred Network Access Commercial |
$3,386.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,803.47
|
| Rate for Payer: Quartz Commercial |
$2,392.36
|
| Rate for Payer: Quartz Medicare Advantage |
$2,208.34
|
| Rate for Payer: The Alliance Commercial |
$1,840.28
|
| Rate for Payer: WEA Trust Commercial |
$2,024.31
|
| Rate for Payer: WPS Commercial |
$2,726.09
|
|
|
KIT GOOSE NECK SNARE 25mm
|
Facility
|
IP
|
$3,539.00
|
|
| Hospital Charge Code |
2973398
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,803.47 |
| Max. Negotiated Rate |
$3,386.12 |
| Rate for Payer: Aetna Commercial |
$3,312.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,165.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,950.70
|
| Rate for Payer: Cash Price |
$1,061.70
|
| Rate for Payer: Cigna Commercial |
$3,386.12
|
| Rate for Payer: Health EOS Commercial |
$3,275.70
|
| Rate for Payer: HFN Commercial |
$3,386.12
|
| Rate for Payer: Multiplan Commercial |
$2,944.45
|
| Rate for Payer: Preferred Network Access Commercial |
$3,386.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,803.47
|
| Rate for Payer: Quartz Commercial |
$2,208.34
|
| Rate for Payer: WEA Trust Commercial |
$2,024.31
|
| Rate for Payer: WPS Commercial |
$2,726.09
|
|
|
KIT GROSHONG REPAIR DUAL 7740000
|
Facility
|
OP
|
$1,907.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
2962891
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$555.32 |
| Max. Negotiated Rate |
$1,824.62 |
| Rate for Payer: Aetna Commercial |
$1,784.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,705.62
|
| Rate for Payer: Aetna Managed Medicare |
$555.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,289.13
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$991.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$951.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,051.14
|
| Rate for Payer: Cash Price |
$572.10
|
| Rate for Payer: Cigna Commercial |
$1,824.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,109.87
|
| Rate for Payer: Health EOS Commercial |
$1,765.12
|
| Rate for Payer: HFN Commercial |
$1,824.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,487.46
|
| Rate for Payer: Multiplan Commercial |
$1,586.62
|
| Rate for Payer: NAPHCARE Commercial |
$1,189.97
|
| Rate for Payer: Preferred Network Access Commercial |
$1,824.62
|
| Rate for Payer: Quartz Beloit One Network |
$971.81
|
| Rate for Payer: Quartz Commercial |
$1,289.13
|
| Rate for Payer: Quartz Medicare Advantage |
$1,189.97
|
| Rate for Payer: The Alliance Commercial |
$991.64
|
| Rate for Payer: WEA Trust Commercial |
$1,090.80
|
| Rate for Payer: WPS Commercial |
$1,468.96
|
|
|
KIT GROSHONG REPAIR DUAL 7740000
|
Facility
|
IP
|
$1,907.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
2962891
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$971.81 |
| Max. Negotiated Rate |
$1,824.62 |
| Rate for Payer: Aetna Commercial |
$1,784.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,705.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,051.14
|
| Rate for Payer: Cash Price |
$572.10
|
| Rate for Payer: Cigna Commercial |
$1,824.62
|
| Rate for Payer: Health EOS Commercial |
$1,765.12
|
| Rate for Payer: HFN Commercial |
$1,824.62
|
| Rate for Payer: Multiplan Commercial |
$1,586.62
|
| Rate for Payer: Preferred Network Access Commercial |
$1,824.62
|
| Rate for Payer: Quartz Beloit One Network |
$971.81
|
| Rate for Payer: Quartz Commercial |
$1,189.97
|
| Rate for Payer: WEA Trust Commercial |
$1,090.80
|
| Rate for Payer: WPS Commercial |
$1,468.96
|
|
|
KIT HIP ARTHROSCOPY MASTER DISPOSABLE WITH BLADE ARTHREX AR-6526S
|
Facility
|
OP
|
$5,130.00
|
|
| Hospital Charge Code |
5074892
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,493.86 |
| Max. Negotiated Rate |
$4,908.38 |
| Rate for Payer: Aetna Commercial |
$4,801.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,588.27
|
| Rate for Payer: Aetna Managed Medicare |
$1,493.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,467.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,667.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,560.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,827.66
|
| Rate for Payer: Cash Price |
$1,539.00
|
| Rate for Payer: Cigna Commercial |
$4,908.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,985.66
|
| Rate for Payer: Health EOS Commercial |
$4,748.33
|
| Rate for Payer: HFN Commercial |
$4,908.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,001.40
|
| Rate for Payer: Multiplan Commercial |
$4,268.16
|
| Rate for Payer: NAPHCARE Commercial |
$3,201.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4,908.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,614.25
|
| Rate for Payer: Quartz Commercial |
$3,467.88
|
| Rate for Payer: Quartz Medicare Advantage |
$3,201.12
|
| Rate for Payer: The Alliance Commercial |
$2,667.60
|
| Rate for Payer: WEA Trust Commercial |
$2,934.36
|
| Rate for Payer: WPS Commercial |
$3,951.64
|
|
|
KIT HIP ARTHROSCOPY MASTER DISPOSABLE WITH BLADE ARTHREX AR-6526S
|
Facility
|
IP
|
$5,130.00
|
|
| Hospital Charge Code |
5074892
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,614.25 |
| Max. Negotiated Rate |
$4,908.38 |
| Rate for Payer: Aetna Commercial |
$4,801.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,588.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,827.66
|
| Rate for Payer: Cash Price |
$1,539.00
|
| Rate for Payer: Cigna Commercial |
$4,908.38
|
| Rate for Payer: Health EOS Commercial |
$4,748.33
|
| Rate for Payer: HFN Commercial |
$4,908.38
|
| Rate for Payer: Multiplan Commercial |
$4,268.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4,908.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,614.25
|
| Rate for Payer: Quartz Commercial |
$3,201.12
|
| Rate for Payer: WEA Trust Commercial |
$2,934.36
|
| Rate for Payer: WPS Commercial |
$3,951.64
|
|
|
KIT HOOK / TRIANGLE BLADE 3056-6
|
Facility
|
OP
|
$2,087.00
|
|
| Hospital Charge Code |
5611596
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$607.73 |
| Max. Negotiated Rate |
$1,996.84 |
| Rate for Payer: Aetna Commercial |
$1,953.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,866.61
|
| Rate for Payer: Aetna Managed Medicare |
$607.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,410.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,085.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,041.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,150.35
|
| Rate for Payer: Cash Price |
$626.10
|
| Rate for Payer: Cigna Commercial |
$1,996.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,214.63
|
| Rate for Payer: Health EOS Commercial |
$1,931.73
|
| Rate for Payer: HFN Commercial |
$1,996.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,627.86
|
| Rate for Payer: Multiplan Commercial |
$1,736.38
|
| Rate for Payer: NAPHCARE Commercial |
$1,302.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,996.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,063.54
|
| Rate for Payer: Quartz Commercial |
$1,410.81
|
| Rate for Payer: Quartz Medicare Advantage |
$1,302.29
|
| Rate for Payer: The Alliance Commercial |
$1,085.24
|
| Rate for Payer: WEA Trust Commercial |
$1,193.76
|
| Rate for Payer: WPS Commercial |
$1,607.62
|
|
|
KIT HOOK / TRIANGLE BLADE 3056-6
|
Facility
|
IP
|
$2,087.00
|
|
| Hospital Charge Code |
5611596
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,063.54 |
| Max. Negotiated Rate |
$1,996.84 |
| Rate for Payer: Aetna Commercial |
$1,953.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,866.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,150.35
|
| Rate for Payer: Cash Price |
$626.10
|
| Rate for Payer: Cigna Commercial |
$1,996.84
|
| Rate for Payer: Health EOS Commercial |
$1,931.73
|
| Rate for Payer: HFN Commercial |
$1,996.84
|
| Rate for Payer: Multiplan Commercial |
$1,736.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,996.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,063.54
|
| Rate for Payer: Quartz Commercial |
$1,302.29
|
| Rate for Payer: WEA Trust Commercial |
$1,193.76
|
| Rate for Payer: WPS Commercial |
$1,607.62
|
|
|
KIT HTR 10MM STERILE 220-10-003
|
Facility
|
OP
|
$4,750.00
|
|
| Hospital Charge Code |
4520500
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,383.20 |
| Max. Negotiated Rate |
$4,544.80 |
| Rate for Payer: Aetna Commercial |
$4,446.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,248.40
|
| Rate for Payer: Aetna Managed Medicare |
$1,383.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,211.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,470.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,371.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,618.20
|
| Rate for Payer: Cash Price |
$1,425.00
|
| Rate for Payer: Cigna Commercial |
$4,544.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,764.50
|
| Rate for Payer: Health EOS Commercial |
$4,396.60
|
| Rate for Payer: HFN Commercial |
$4,544.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,705.00
|
| Rate for Payer: Multiplan Commercial |
$3,952.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,964.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,544.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,420.60
|
| Rate for Payer: Quartz Commercial |
$3,211.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,964.00
|
| Rate for Payer: The Alliance Commercial |
$2,470.00
|
| Rate for Payer: WEA Trust Commercial |
$2,717.00
|
| Rate for Payer: WPS Commercial |
$3,658.93
|
|
|
KIT HTR 10MM STERILE 220-10-003
|
Facility
|
IP
|
$4,750.00
|
|
| Hospital Charge Code |
4520500
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,420.60 |
| Max. Negotiated Rate |
$4,544.80 |
| Rate for Payer: Aetna Commercial |
$4,446.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,248.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,618.20
|
| Rate for Payer: Cash Price |
$1,425.00
|
| Rate for Payer: Cigna Commercial |
$4,544.80
|
| Rate for Payer: Health EOS Commercial |
$4,396.60
|
| Rate for Payer: HFN Commercial |
$4,544.80
|
| Rate for Payer: Multiplan Commercial |
$3,952.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,544.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,420.60
|
| Rate for Payer: Quartz Commercial |
$2,964.00
|
| Rate for Payer: WEA Trust Commercial |
$2,717.00
|
| Rate for Payer: WPS Commercial |
$3,658.93
|
|
